Compelling evidence from a recent randomized trial has prompted the American Society for Clinical Oncology to recommend that palliative care be integrated early on into standard cancer therapies for patients with metastatic cancers or a high burden of cancer symptoms.
Potentially practice changing, the opinion is based on the best currently available clinical evidence. Palliative care is typically relegated to the final days of life of patients with advanced metastatic cancers, as it is provided only after all other options have failed.
Authors of the opinion, intended to offer guidance to oncologists on this issue, cite a study published in 2010 (N. Engl. J. Med. 2010;363:733-42). The study showed that patients who were randomized to palliative care plus standard therapy for metastatic non–small cell lung cancer (NSCLC) had significantly longer overall survival than did patients randomized to standard care alone, (11.6 vs. 8.9 months, P = .02), even though the palliative care group had less aggressive end-of-life care.
Patients receiving palliative care also had significantly better quality of life scores on a standardized assessment scale, and significantly fewer had depressive symptoms, compared with patients on standard care.
Dr. Thomas J. Smith
"While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care – when combined with standard cancer care or as the main focus of care – leads to better patient and caregiver outcomes. These include improvement in symptoms, quality of life, and patient satisfaction, with reduced caregiver burden," wrote Dr. Thomas J. Smith and his colleagues in an American Society of Clinical Oncology (ASCO) provisional clinical opinion published online Feb. 6 in the Journal of Clinical Oncology (doi:10.1200/JCO.2011.38.5161).
Palliative care also eases patients and families through the anguish of dashed hopes and has the potential to reduce costs by limiting expensive but often futile intensive hospital-based services, the authors wrote.
"All the data suggest that there’s absolutely no harm from earlier integration of hospice and palliative medicine into patient care. A couple of trials have shown improved survival, and there are very good data from observational studies that people who use hospice actually live longer," Dr. Smith said in an interview. He is director of palliative care for Johns Hopkins University and Hopkins’ Sidney Kimmel Comprehensive Cancer Center in Baltimore.
Dr. Jennifer Temel
"I think that ASCO is sending a really strong message to oncologists that we need to do more than we’re currently doing and that comprehensive cancer care needs to included supportive care on top of cancer-directed therapy," said Dr. Jennifer S. Temel, clinical director of thoracic oncology at Massachusetts General Hospital in Boston, and lead author of the randomized trial mentioned earlier.
She noted, however, that the study was not powered to detect an overall survival benefit. "All we were hoping for was that early palliative care didn’t lead to a survival detriment ... people could have been concerned that because of the involvement of palliative care, patients would receive less-intensive therapy and have shorter survival," Dr. Temel said. "I’m just very happy that’s not what we saw, but whether the survival benefit we saw was real and will be replicated, we'll have to wait and see."
The primary value of the study, she added, is that it demonstrated distinct benefits of palliative care on patient mood and quality of life.
The Will but Not the Way?
But many oncology practices, particularly those in community settings, may not have the resources to provide a full complement of palliative care services, said an oncologist in community-based practice.
"Those types of palliative care options are not widely available, and they certainly aren’t available in smaller communities," said Dr. Patrick Cobb, managing partner at the Frontier Cancer Center in Billings, Mont.
Dr. Patrick Cobb
Services required for effective palliative care, such as patient and family counseling, are not typically reimbursed under current payments systems. In addition, palliative care reimbursement is often an "either/or" proposition: insurers pay for either therapeutic services or hospice care, but not both, said Dr. Cobb, former president of the Community Oncology Alliance.
He added that the so-called Stark law – actually a set of provisions in federal law governing the ability of clinicians to refer patients to clinical or diagnostic facilities in which the clinician has a financial interest – is another barrier to palliative care in the community, particularly in rural areas where the population may not be large enough to support separate palliative care facilities or programs.